Andrew Zura

A phase IIIb, randomized, double-blind, placebo-controlled, multicenter study evaluating the safety and efficacy of dexmedetomidine for sedation during awake fiberoptic intubation

GABA-mediated sedatives have respiratory depressant properties that may be detrimental in patients with difficult airways. In this randomized, double-blind, multicenter, Phase IIIb Food and Drug Administration study, safety and efficacy of dexmedetomidine compared with placebo were evaluated as the primary sedative for awake fiberoptic intubation (AFOI). Patients were randomized to receive dexmedetomidine or saline. Patients were sedated with dexmedetomidine or rescue midazolam to achieve targeted sedation (Ramsay Sedation Scale ≥ 2) before topicalization and throughout AFOI. Primary efficacy endpoint was percentage of patients requiring rescue midazolam; secondary efficacy endpoints were total dose of rescue midazolam, percentage requiring additional rescue nonmidazolam medications, anesthesiologists assessment of ease of subject care, and patient recall and satisfaction 24 hours postoperatively. Less rescue midazolam was required to maintain Ramsay Sedation Scale ≥2 (47.3% vs. 86.0%, P < 0.001), and supplemental midazolam dose was lower (1.07 ± 1.5 mg vs. 2.85 ± 3.0 mg, P < 0.001) with dexmedetomidine compared with placebo. More Mallampati Class IV patients treated with dexmedetomidine were successfully intubated without midazolam than with placebo (66.7% vs. 8.3%, P = 0.009). Dexmedetomidine decreased blood pressure and heart rate compared with placebo patients sedated with midazolam. Patients and anesthesiologists showed favorable satisfaction responses in both groups. Adverse events and patient recall were similar in both groups. Dexmedetomidine is effective as the primary sedative in patients undergoing AFOI. Some patients may require small supplemental doses of midazolam, in addition to dexmedetomidine, to achieve sufficient sedation for AFOI. Dexmedetomidine provides another AFOI option for sedation of patients with difficult airways.

Use of the Aintree intubation catheter in a patient with an unexpected difficult airway.

PurposeTo present a case where the Aintree intubation catheter® (AIC) was used in conjunction with the Laryngeal Mask Airway® (LMA) and a fibreoptic bronchoscope (FOB) in a patient with an unexpected difficult airway.Clinical featuresA 38-yr-old 90 kg man scheduled for nasal endoscopy with ethmoidectomy under general anesthesia was found, unexpectedly, to be difficult to intubate using both a Macintosh laryngoscope (#4 blade) and a GlideScope® video laryngoscope despite having an airway examination that was unremarkable except for slightly decreased mouth opening and a large tongue. Intubation was achieved by inserting a size 5 disposable LMA into the upper airway, introducing a FOB into an AIC inserting the FOB/AIC assembly into the trachea via the LMA, removing the LMA, and then passing a regular size (7.5 mm) endotracheal tube into the trachea over the AIC.ConclusionIn this patient, the AIC provided an effective alternative to other methods for intubating through a regular LMA.RésuméObjectifPrésenter un cas où le Aintree intubation catheter® (AIC) a été utilisé en conjonction avec le Laryngeal Mask Airway® (LMA) et un fibroscope bronchique (FOB) dans un cas d’intubation difficile imprévue.Éléments cliniquesUn homme de 38 ans, pesant 90 kg, devant subir une endoscopie nasale et une ethmoïdectomie sous anesthésie générale a été, de façon inattendue, difficile à intuber avec un laryngoscope Macintosh (lame 4) et un vidéo-laryngoscope GlideScope® malgré un examen des voies aériennes qui était sans particularité sauf pour une ouverture de la bouche légèrement réduite et une grosse langue. L’intubation a été réalisée en insérant un MLA jetable de taille 5 dans les voies aériennes supérieures, en introduisant une FOB dans un AIC et en insérant ce FOB/AIC rassemblé dans la trachée au travers du LMA, puis en enlevant le MLA et en passant ensuite un tube endotrachéal de taille régulière (7,5 mm) dans la trachée au-dessus de l’AIC.ConclusionChez le patient présenté, l’AIC a été utilisé en remplacement d’autres méthodes d’intubation au travers d’un LMA régulier.

Medical resources for the anesthesiologist on the Internet.

Background and Objectives: The Internet may be the most powerful information tool currently available to medical professionals. The first article in this Internet series (Reg Anesth Pain Med 1999;24:369‐374) served as an introduction to the World Wide Web, while this article describes specific resources available to anesthesiologists searching for medical information. Editors Note: This series of articles on information technology describes a number of resources. Inclusion in this article does not imply endorsement or support by the American Society of Regional Anesthesia and Pain Medicine (ASRA‐PM). Each reader is encouraged to personally evaluate specific websites because of the rapidly changing content and location of information on the Internet. This article is available on the ASRA‐PM website (www.ASRA.com) with updated links to websites in this article.

Use of the CTrach Laryngeal Mask Airway in adult patients: a retrospective review of 126 cases☆

STUDY OBJECTIVE To evaluate the effectiveness of the CTrach Laryngeal Mask Airway (LMA) when used electively. DESIGN Retrospective analysis. SETTING Operating room of an academic hospital. MEASUREMENTS Data from 126 patients who were electively intubated with the CTrach LMA over a 16-month period were reviewed. Each patients weight, height, ASA physical status classification, Mallampati score, thyromental distance, and cervical spine range of motion were recorded. MAIN RESULTS Successful ventilation was achieved in 100% of patients, while successful intubation was achieved in 89.7% of patients. The most common reason for failure to intubate was poor airway visualization and the inability to appropriately position the device anterior to the vocal cords. CONCLUSIONS The major advantage of the CTrach LMA is that it is the only device that allows airway visualization during patient ventilation; however, it does not have 100% success with intubation.

Postoperative Stridor and Acute Respiratory Failure After Parkinson Disease Deep Brain Stimulator Placement: Case Report and Review of Literature

BACKGROUND Parkinson disease (PD), a neurodegenerative disorder characterized by loss of dopaminergic neurons in the substantia nigra of the midbrain, is commonly thought of as a motion disorder, but it can have significant effect on the respiratory system. Respiratory failure is the most common cause of death in these patients, but it can also affect laryngeal function causing dysphonia, dysphagia, and dysarthric speech. Acute upper airway obstruction is a rare finding in PD, especially in the perioperative settings. In this article we report a PD patient who developed upper respiratory obstruction postoperatively. We also review the literature and highlight the importance of preoperative evaluation to identify patients who may be at risk of this complication. CASE DESCRIPTION We describe a PD patient presenting for brain stimulation electrode implantation under general anesthesia, who postoperatively developed stridor and near complete upper airway obstruction despite maintenance of oral anti-Parkinson medication regimen intraoperatively. The patient was reintubated in post-anesthesia-care unit, and tracheostomy was performed after 1 week due to persistent vocal cord dysfunction. CONCLUSIONS Baseline vocal cord impairment in PD patients can be acutely aggravated perioperatively. Symptoms such as dysphagia and dysarthria, which can indicate susceptibility to postoperative upper airway obstruction, may not be well recognized by the patient and family. Surgical candidates should be carefully interviewed preoperatively, and watchful monitoring of respiratory function intraoperatively and postoperatively is of paramount importance. Neurosurgical and neuroanesthesia team should be aware of, and prepared to manage, this potentially life-threatening airway obstruction in PD patients.

An introduction to digital cameras.

Background and Objectives People in all walks of life are using digital cameras instead of the traditional film cameras. Reasons include simplicity of use, ease of development, ability to incorporate the pictures into documents, potential to edit the pictures easily, and capability to send them by e-mail. This article will briefly discuss digital cameras, how they work, what they can do, and what you should look for in one. Editor’s Note This is the fourth in a series of articles demonstrating and describing information technology. The articles include nontechnical information and are geared toward the computer novice with interest in regional anesthesia and pain medicine.